GW1-2022-07100_Well Construction - GW1_20220801

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Chris C Russell -14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
y
3254A 60 ft. 200
ft ft.
NC Well Contractor Certification Number Inc15.OUTER CASING for multi cased wells OR LINER if a licable
Russell Well Drilling, c FROM TO D1i=MnRIf THICKNESS MATERIAL
0 ft 96 ft 6.25 SDR21 PVC
Company Name
327634 -16.INNER CASING OR TOBING(geothermal closed-loo '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft in.
3.Well Use(check well use): fL ft. in.
17.
Water Supply Well: FROM SCREEN.TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) @Residential Water Supply(single) ft. ft. in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑lrri ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft- Grout: Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL-PACK K if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer -20.DRILLING LOG attach additlodbi sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION rot ttlees v rein size,etc.)
0 fL 91 fL Dirt CutVVED
4.Date Well(s)Completed: 6-23-2022 Well ID# 91 ft. 200 ft. ROCK
AUG
Sa.Well Location: ft. ft. i
Ashley Plyer Jeremy Plyer fL fL InkfAialio., Prime U
Facility/Owner Name Facility ID#(if applicable) ft. ft.
402 Shiloh Rd, Statesville, NC 28625 ft. ft.
Physical Address,City,and Zip ft. ft.
Iredeil 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2-21 Certification:
35' 74.315' N 080' 82.7991 W - 7/13/2022
6.Is(are)the well(s): R]Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 200 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 t200'and 2@I00')
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24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 6 ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy 6 DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC E 7699-1636
12.Well construction method: Air Drilled
24c.For Water Supply and Open'-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depart I ment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 10 u u Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1/2 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource, Revised 6-6-2018
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